Bottom Line:
Our patient was started on high-dose steroids and showed dramatic improvement within 48 hours.We report the first adult case of drug reaction with eosinophilia and systemic symptoms syndrome associated with azithromycin exposure.Clinicians should be aware of this potentially devastating complication from this commonly prescribed medication.

Introduction: Drug reaction with eosinophilia and systemic symptoms syndrome is a potentially life-threatening cutaneous hypersensitivity reaction characterized by extensive mucocutaneous eruption, fever, hematologic abnormalities including eosinophilia and/or atypical lymphocytosis, and extensive organ involvement. The drugs most often responsible for causing drug reaction with eosinophilia and systemic symptoms syndrome are anticonvulsants, antimicrobial agents and antipyretic or anti-inflammatory analgesics. Although azithromycin is widely prescribed in clinical practice, serious cutaneous reactions from this agent have been rarely described. We report the first adult case of drug reaction with eosinophilia and systemic symptoms syndrome associated with azithromycin.

Case presentation: A 44-year-old previously healthy Caucasian man with history of tobacco use presented to his primary care physician with fever and productive cough. He was prescribed azithromycin, promethazine hydrochloride and dextromethorphan hydrobromide syrup. One week later, he developed a blistering erythematous rash over both hands, which over the next two weeks spread to involve nearly his entire body surface, sparing only his face. He was admitted to an outside hospital with signs of systemic inflammatory response syndrome and severe sepsis, presumably from a skin infection. Despite aggressive therapy he deteriorated, with worsening diffuse erythema, and was transferred to our institution. He developed multiple organ failure requiring ventilatory and hemodynamic support. Pertinent laboratory studies included a leukocytosis with a white blood cell count of 17.6 × 10(9)/L and 47% eosinophils. A skin biopsy showed evidence of spongiotic lichenoid dermatitis with eosinophils and neutrophils, compatible with a systemic drug-induced hypersensitivity reaction. Our patient was started on high-dose steroids and showed dramatic improvement within 48 hours.

Conclusions: We report the first adult case of drug reaction with eosinophilia and systemic symptoms syndrome associated with azithromycin exposure. Clinicians should be aware of this potentially devastating complication from this commonly prescribed medication.

Figure 1: (A) Left leg, (B) left foot, (C) right hand and (D) trunk with ill-defined coalescing erythema from head to toe with diffuse pinpoint petechiae. Keratotic desquamation of palms and soles.

Mentions:
A 44-year-old otherwise healthy Caucasian man, with a past medical history of anxiety and 15 pack year tobacco use, initially presented to his primary care physician with several days onset of fevers, congestion and cough. He was prescribed azithromycin, promethazine hydrochloride and dextromethorphan hydrobromide syrup. One week later, the patient developed an acute diffuse blistering morbilliform erythematous rash involving bilateral hands, which was extremely pruritic and associated with high-grade fever. Within two weeks, the rash spread to involve nearly his entire body surface, sparing only his face. He presented to an outside hospital with persistent fever, rash, and hypotension consistent with systemic inflammatory response syndrome. He was treated for severe sepsis and presumptive superimposed skin infection with vancomycin and aztreonem, given his history of penicillin allergy. Despite aggressive therapy, the patient rapidly deteriorated with worsening skin involvement, and was subsequently transferred to our institution for higher level care.Upon arrival, his vital signs were temperature of 38.2°C, blood pressure of 95/20mmHg, heart rate 68 beats/min, respiratory rate 20 breaths/min, and oxygen saturation 95% on 2L nasal canula. Shortly thereafter, our patient became hypotensive despite aggressive fluid resuscitation and was started on norepinephrine. Our patient was subsequently intubated due to worsening level of consciousness. A physical examination revealed an ill-appearing sedated man with evidence of generalized ill-defined coalescing erythema and diffuse pinpoint petechiae. A pulmonary examination was notable for bilateral crackles and diffuse rhonchi and a cardiovascular examination was normal except for tachycardia. There was no lymphadenopathy. A detailed skin examination (Figure 1) revealed keratotic desquamation of his palms and soles. His lips and oral mucosa were dry with some cracking of vermilion lips but no bullae. His tongue was diffusely red. His conjunctivae were injected. There were no vesicles, bullae, or target lesions seen. The Nikolsky sign was negative.

Figure 1: (A) Left leg, (B) left foot, (C) right hand and (D) trunk with ill-defined coalescing erythema from head to toe with diffuse pinpoint petechiae. Keratotic desquamation of palms and soles.

Mentions:
A 44-year-old otherwise healthy Caucasian man, with a past medical history of anxiety and 15 pack year tobacco use, initially presented to his primary care physician with several days onset of fevers, congestion and cough. He was prescribed azithromycin, promethazine hydrochloride and dextromethorphan hydrobromide syrup. One week later, the patient developed an acute diffuse blistering morbilliform erythematous rash involving bilateral hands, which was extremely pruritic and associated with high-grade fever. Within two weeks, the rash spread to involve nearly his entire body surface, sparing only his face. He presented to an outside hospital with persistent fever, rash, and hypotension consistent with systemic inflammatory response syndrome. He was treated for severe sepsis and presumptive superimposed skin infection with vancomycin and aztreonem, given his history of penicillin allergy. Despite aggressive therapy, the patient rapidly deteriorated with worsening skin involvement, and was subsequently transferred to our institution for higher level care.Upon arrival, his vital signs were temperature of 38.2°C, blood pressure of 95/20mmHg, heart rate 68 beats/min, respiratory rate 20 breaths/min, and oxygen saturation 95% on 2L nasal canula. Shortly thereafter, our patient became hypotensive despite aggressive fluid resuscitation and was started on norepinephrine. Our patient was subsequently intubated due to worsening level of consciousness. A physical examination revealed an ill-appearing sedated man with evidence of generalized ill-defined coalescing erythema and diffuse pinpoint petechiae. A pulmonary examination was notable for bilateral crackles and diffuse rhonchi and a cardiovascular examination was normal except for tachycardia. There was no lymphadenopathy. A detailed skin examination (Figure 1) revealed keratotic desquamation of his palms and soles. His lips and oral mucosa were dry with some cracking of vermilion lips but no bullae. His tongue was diffusely red. His conjunctivae were injected. There were no vesicles, bullae, or target lesions seen. The Nikolsky sign was negative.

Bottom Line:
Our patient was started on high-dose steroids and showed dramatic improvement within 48 hours.We report the first adult case of drug reaction with eosinophilia and systemic symptoms syndrome associated with azithromycin exposure.Clinicians should be aware of this potentially devastating complication from this commonly prescribed medication.

Introduction: Drug reaction with eosinophilia and systemic symptoms syndrome is a potentially life-threatening cutaneous hypersensitivity reaction characterized by extensive mucocutaneous eruption, fever, hematologic abnormalities including eosinophilia and/or atypical lymphocytosis, and extensive organ involvement. The drugs most often responsible for causing drug reaction with eosinophilia and systemic symptoms syndrome are anticonvulsants, antimicrobial agents and antipyretic or anti-inflammatory analgesics. Although azithromycin is widely prescribed in clinical practice, serious cutaneous reactions from this agent have been rarely described. We report the first adult case of drug reaction with eosinophilia and systemic symptoms syndrome associated with azithromycin.

Case presentation: A 44-year-old previously healthy Caucasian man with history of tobacco use presented to his primary care physician with fever and productive cough. He was prescribed azithromycin, promethazine hydrochloride and dextromethorphan hydrobromide syrup. One week later, he developed a blistering erythematous rash over both hands, which over the next two weeks spread to involve nearly his entire body surface, sparing only his face. He was admitted to an outside hospital with signs of systemic inflammatory response syndrome and severe sepsis, presumably from a skin infection. Despite aggressive therapy he deteriorated, with worsening diffuse erythema, and was transferred to our institution. He developed multiple organ failure requiring ventilatory and hemodynamic support. Pertinent laboratory studies included a leukocytosis with a white blood cell count of 17.6 × 10(9)/L and 47% eosinophils. A skin biopsy showed evidence of spongiotic lichenoid dermatitis with eosinophils and neutrophils, compatible with a systemic drug-induced hypersensitivity reaction. Our patient was started on high-dose steroids and showed dramatic improvement within 48 hours.

Conclusions: We report the first adult case of drug reaction with eosinophilia and systemic symptoms syndrome associated with azithromycin exposure. Clinicians should be aware of this potentially devastating complication from this commonly prescribed medication.